Accurately assesses residents' health status as well as their educational and environmental needs on admission and on an ongoing basis. Remains aware about and communicates to the appropriate interdisciplinary team (IDT) member any significant change in condition. Accurately documents all assessments. Develops dynamic care plans based upon the identified needs of the residents through an interdisciplinary approach that includes physicians, residents, families, and other IDT members. Reviews and revises the care plan as the resident's needs, problems, and goals change. Communicates the plan to the appropriate IDT members along with the residents and families. Accurately documents the care plan on admission, cognition change, or regulatory requirements for care planning. Identifies necessary nursing interventions relevant to the plan of care which includes nursing orders, physician orders, residents/families educational and environmental needs. Interventions such as medication administration, treatments, and IV fluid administrations are accomplished in a safe and timely manner. Documents all interventions accurately and timely. Uses critical thinking skills when dealing with residents' change in condition. Notifies the physician timely using the SBARR as the communication tool. Maintains composure during and handles any crisis situation such as family dissatisfaction, staff disputes, or inclement weather in a calm and professional manner. Monitors the care of the residents closely to see that the care plan is being delivered effectively. Identifies problem areas and uses the QAPI process to actively address the situation for immediate problem resolution. Remains knowledgeable about the status of the resident to quickly identify behavioral changes or other untoward signs or symptoms. Assists in answering call lights and assists with resident care such as ADLs. Completes twelve hours, at a minimum, of offerings related to nursing. Upholds commitment to remaining current in best nursing practices through knowledge of Bethesda's policies and self-study. May be assigned other duties as appropriate.
